Search

Coronary artery calcium (CAC) is a frequent incidental finding on computed tomography pulmonary angiogram (CTPA) in the evaluation of pulmonary embolism (PE) in the emergency department (ED); however, its prognostic value is unclear. In this study, we interrogate the prognostic value of CAC identified on CTPA in predicting adverse outcomes in the evaluation of PE in the ED.In this retrospective cohort study, we identified 610 patients presenting to the ED in 2013 and evaluated with CTPA for suspected PE. Ordinal CAC scores were evaluated as absent (0), mild (1), moderate (2), or severe (3) in each of the 4 main coronary arteries. Composite CAC scores were subsequently compared against adverse clinical outcomes, defined as intensive care unit admission, hospital stay longer than 72 hours, or death during hospital course or at 6-month follow-up, using univariate and multivariate logistic regression analyses. Relevant exclusion criteria included a history of cardiovascular disease.In all, 365 patients met the inclusion criteria (231 women, mean age 56±16 y) with 132 patients (36%) having some degree of CAC and 16 (4%) having severe CAC. Known malignancy was present in 151 (41%) patients and composite adverse clinical outcomes were observed in 98 patients (32%). Age, presence of acute PE, malignancy, and presence of CAC were significant predictors of adverse outcomes on both univariate and multivariate analyses. CAC was not an independent predictor of short-term adverse outcomes on multivariate analysis ( P =0.06) when all patients were considered. However, when patients with known malignancy were excluded, CAC was an independent predictor of short-term adverse outcomes (odds ratio=2.5, confidence interval=1.1-5.5, P =0.03) independent of age and presence of PE.The presence of CAC on CT PA was predictive of adverse outcomes in patients without known cardiac disease presenting to the ED with suspected PE.

We aimed to evaluate the impact of collaborative discussion between diagnostic radiologists and radiation oncologists on radiation oncology management for thoracic oncology patients.We reviewed cases presented at multidisciplinary thoracic tumor boards (TTB) (n = 122) and diagnostic radiology/radiation oncology rounds (DR/ROR) (n = 45). Changes in planned radiation management following imaging discussion were categorized-no change, timing change, and treatment volume change. Phase of care was also classified. In DR/ROR, radiation oncologists were surveyed regarding (1) change in radiation oncology management and (2) change in confidence (both 5-point Likert scales).Discussion of imaging with a radiologist changed radiation oncology management in 31.1% of TTB cases and 68.9% of DR/ROR cases (P0.001). Changes to the timing of initiating radiation therapy occurred with similar frequency in the 2 settings (31.1% vs 46.7%, P = 0.063). Changes to target volume occurred more frequently in DR/ROR (35.6% vs1%), P0.001. Over half of imaging discussions in DR/ROR resulted in at least "moderate" change in radiation oncology management, and the level of confidence held by the radiation oncologists increased following discussion with radiologists in 95.6% of cases.Collaborative discussions between radiation oncologists and diagnostic radiologists in a multispecialty tumor board and in targeted 2-specialty rounds are not redundant, but result in different management changes and at different phases of care. Our study emphasizes the importance of consultation with physicians as an area where radiologists can add value, specifically the added benefit of smaller collaborative discussions.

Objective To investigate whether general psychological motivating factors that guide career selection of a medical specialty differ over the course of medical school and to compare differences in motivating factors among students choosing "controllable" lifestyle specialties, students choosing "uncontrollable" lifestyle specialties, and a cohort of radiology residents. Materials and Methods An anonymous survey was distributed to first- through fourth-year medical students and radiology residents at a single institution. Participants were asked to select their top three of seven factors that most influenced their choice of medical specialty. Fourth-year students were asked to designate the specialty to which they had applied. Results The survey was distributed to 259 students and 47 radiology residents with a response rate of 93.8% (243 of 259) and 95.7% (45 of 47), respectively. The top three factors indicated by medical students were finding the daily work fulfilling, work–life balance, and interest in the subject. These top three factors were common to all medical student classes and did not differ between students choosing "controllable" versus "uncontrollable" fields. The factors uncommonly selected were similar personality to others in the field, attending income, competitiveness or prestige, and job market conditions. For radiology residents, the top three motivating factors were the same as for medical students. Conclusion Three out of seven motivating factors were universally important to trainees, regardless of their stage of medical training or their selection of a controllable versus uncontrollable lifestyle specialty. These data suggest the variety of career choices made by students may not derive from differing underlying values.

The objective of our study was to assess the frequency and time frame with which CT-guided lung biopsies for suspected infection yield information that can affect patient management.All CT-guided lung biopsies over a 68-month period performed for the purpose of diagnosing a suspected infection were reviewed to determine the proportion that yielded information affecting patient management. Patients were included if infection was the only consideration causing the pulmonary lesion in question.Twenty-one biopsies were performed to identify a specific organism causing infection in patients with suspected infection; all patients were receiving antibiotics, 20 (95%) were immunocompromised, and 15 (71%) had undergone a prior bronchoscopy. Material collected from the biopsy provided a diagnosis in nine (43%) patients, whereas the biopsy results were nondiagnostic in the remaining 12 (57%). Of the nine patients for whom the biopsy yielded a diagnosis, eight biopsies revealed the species causing an infection (38%) and one biopsy (5%) detected posttransplant lymphoproliferative disease. Of the nine diagnoses, management was changed as a result of the biopsy in six patients (29% of all patients). The organisms identified by CT-guided lung biopsy in eight patients were fungi of the order Mucorales (i.e., mucormycosis) (n = 3), Aspergillus (n = 3), Pseudomonas (n = 1), and Nocardia (n = 1). The mean elapsed time between biopsy and pathologic diagnosis was 4 days (median, 3 days). There was no association between prior bronchoscopy and nondiagnostic biopsy results.CT-guided lung biopsies in patients with a high pretest suspicion for infection result in information sufficient to change patient management in 29% of patients. Organisms identified in these patients were most frequently fungi.

BothForty-one consecutive patients with high-grade gliomas (20 with grade IV gliomas and 21 with grade III gliomas) underwent a standardized tumor protocol performed using an integrated 3-T PET-MRI scanner. Quantitative measures of standardized uptake value, plasma volume, and permeability were obtained from segmented whole-tumor volumes of interest and targeted ROIs. ROC curve analysis and the Youden index were used to identify optimal cutoffs for FDG PET and DCE-MRI. Two-by-two contingency tables and percent agreement were used to assess accuracy and concordance. Twenty-six patients (63%) from the cohort underwent next-generation sequencing for tumor genetics.The best-performing FDG PET and DCE-MRI cutoffs achieved sensitivities of 94% and 91%, respectively; specificities of 56% and 89%, respectively; and accuracies of 80% and 83%, respectively. FDG PET and DCE-MRI findings were discordant for 11 patients (27%), with DCE-MRI findings correct for six of these patients (55%). Tumor grade, tumor volume, bevacizumab exposure, and time since radiation predicted discordance between FDG PET and DCE-MRI findings, with an ROC AUC value of 0.78. Isocitrate dehydrogenase gene and receptor tyrosine kinase gene pathway mutations increased the ROC AUC value to 0.83.FDG PET and DCE-MRI show comparable accuracy and sensitivity in identifying tumor progression. These modalities were shown to have discordant findings for more than a quarter of the patients assessed. Tumor genetics may contribute to perfusion-metabolism discordance, warranting further investigation.

© 2016 The Association of University Radiologists Rationale and Objectives We aimed to evaluate whether implementation of a low-dose computed tomography (CT)-guided lung biopsy protocol, with the support of individual radiologists in the section, would lead to immediate and sustained decreases in radiation dose associated with CT-guided lung biopsies. Materials and Methods A low-dose CT-guided lung biopsy protocol was developed with modifications of kilovoltage peak, milliamperes, and scan coverage. Out of 413 CT-guided lung biopsies evaluated over a 3-year period beginning in 2009, 175 performed with a standard protocol before the development of a low-dose protocol, and 238 performed with a low-dose protocol. The dose-length product (DLP) was recorded for each lung biopsy and retrospectively compared between the two protocols. Individual radiologist level DLPs were also compared before and after the protocol change. Results The mean biopsy dose decreased by 64.4% with the low-dose protocol (113.8 milligray centimeters versus 319.7 milligray centimeters; P

© 2016, Springer Science+Business Media Dordrecht. To evaluate the association between aortic morphology and elasticity with aortic regurgitation in surgically corrected of tetralogy of Fallot (TOF) patients. We retrospectively identified 72 consecutive patients with surgically corrected TOF and 27 healthy controls who underwent cardiac MRI evaluation. Velocity-encoded cine MRI was used to quantify degree of aortic regurgitation (AR) in TOF patients. Ascending aorta diameters were measured at standard levels on MRA images. Aortic pulse-wave velocity (PWV) was quantified with MRI. Morphological and functional MRI variables were compared between groups of TOF patients with and without clinically relevant AR and controls. The association between aortic morphology and elasticity with the presence of AR was evaluated using univariate and multivariate logistic regression. The majority of TOF patients had only trace AR. Nine TOF patients (12 %) had an AR fraction higher than 15 %. Indexed aorta diameter at the sinotubular junction (p = 0.007), at the RPA level (p = 0.006), and low left ventricular ejection fraction (LVEF) (p = 0.015) showed the strongest associations with the presence of at least mild AR, which persisted after controlling for age and gender. Increased ascending aorta dimension is associated with AR in patients after repair of TOF. LVEF was also low in the group of patients with relevant AR compared to those without, suggesting even mild to moderate AR may contribute to LV dysfunction in these patients. Enlarged ascending aorta may be an indication for precise quantification of regurgitant fraction with MRI, since symptomatic patients may need aortic valve repair when moderate regurgitation is present.

PurposeComputed tomography (CT) use in emergency departments represents a significant contribution to pediatric patients' exposure to ionizing radiation. Here, we evaluate whether ultralow-dose chest CT can be diagnostically adequate for other diagnoses and whether model-based iterative reconstruction (MBIR) can improve diagnostic adequacy compared to adaptive statistical iterative reconstruction (ASIR) at ultralow doses.MethodsTwenty children underwent chest CTs: 10 standard-dose reconstructed with ASIR and 10 ultralow-dose reconstructed with ASIR and MBIR. Four radiologists assessed images for their adequacy to exclude five hypothetical diagnoses: foreign body, fracture, lung metastasis, pulmonary infection, and interstitial lung disease. Additionally, pairwise comparison for subjective image quality was used to compare ultralow-dose chest CT with ASIR and MBIR. Radiation dose and objective image noise measures were obtained.ResultsFor exclusion of an airway foreign body, the adequacy of ultralow-dose CT was comparable to standard-dose (p=0.6). For the remaining diagnoses, ultralow-dose CT was inferior to standard-dose (p=0.03

Rationale and Objectives Most fluorine-18 fluorodeoxyglucose (FDG)-positron emission tomography with computed tomography (PET/CT) studies are performed on cancer patients. These patients are at increased risk of pulmonary embolism (PE). In this retrospective review, we determined the rate of PE, and the prevalence of associated FDG-PET findings on intravenous (IV) contrast-enhanced PET/CT. Materials and Methods We identified all PET/CT studies performed at our institution with a reported finding of PE between January 2005 and October 2012. The medical record was reviewed for symptoms, which were identified after the diagnosis of PE, and whether the patients received treatment. The prevalence of associated FDG-PET findings was determined. Results A total of 65 total cases of PE (of 182,72 total PET/CT examinations) were identified of which 59 were previously unknown. This gives an incidental PE (IPE) rate of 0.32%. Of the patients where sufficient clinical information was available, 34 of 36 (94%) were treated either with therapeutic anticoagulation or inferior vena cava filter, and 30 of 36 (83%) were asymptomatic in retrospect. Of the patients with IPE, we found nine (15.2%) with associated focal pulmonary artery hypermetabolism, three (5.1%) with hypermetabolic pulmonary infarction, and one with increased isolated right ventricular FDG uptake (1.7%). One case of chronic PE demonstrated a focal hypometabolic filling defect in a pulmonary artery on PET. Conclusions We found IPE in 0.32% of PET/CT scans. Focal pulmonary artery hypermetabolism or hypometabolism, and hypermetabolic pulmonary artery infarction with the “rim sign” were uncommonly associated with PE. These findings could raise the possibility of IPE in non-IV contrast-enhanced PET/CT studies.

O RIGINAL A RTICLE Nonclotted Blood Patch Technique Reduces Pneumothorax and Chest Tube Placement Rates After Percutaneous Lung Biopsies Joshua D. Clayton, MD,* Brett M. Elicker, MD, w Karen G. Ordovas, MD, w Maureen P. Kohi, MD, w Janet Nguyen, MD, w and David M. Naeger, MD w Purpose: The aim of this study was to determine whether autolo- gous nonclotted blood patch decreases pneumothorax and chest tube placement rates in computed tomography–guided biopsies of the lung. Materials and Methods: Percutaneous computed tomography– guided lung biopsies performed over a period of 6 years were retrospectively reviewed to determine the overall rates of pneu- mothorax and chest tube placement and rates before and after the autologous nonclotted blood patch procedure was instituted as a departmental policy. The effect of the intervention was only assessed in patients in whom a blood patch could be applied, therefore only when the needle traversed an aerated lung and only when the needle remained in the lung at the end of the study. Results: There was a statistically significant decrease in both the rate of pneumothorax [28% (69/245) vs. 42% (80/189); P = 0.002] and chest tube placement [4% (10/245) vs. 16% (30/189); P < 0.001] in patients who received nonclotted blood patch versus those who did not. Blood patch was performed in 222/312 (71%) eligible patients after the introduction of the blood patch policy. After policy introduction, there was a decreased rate of pneumo- thorax, with a rate of 32% (101/312) versus 40% (49/122) (P = 0.12) and a statistically significant decrease in departmental chest tube placement rates of 6% (20/312) versus 16% (20/122) (P = 0.001). Conclusions: Nonclotted autologous blood patch for percutaneous lung biopsy resulted in significantly decreased pneumothorax and chest tube placement rates in our patient population. Key Words: percutaneous lung biopsy, lung biopsy, pneumothorax, chest tube, blood patch, autologous blood patch, sealant (J Thorac Imaging 2016;31:243–246) emphysema, varying needle size, depth and angle of tra- jectory, and postprocedural patient positioning (patient supine, puncture side down, etc.). 1–8 Sealant techniques have been an area of debate since their initial description. Many sealant materials have been studied, with autologous clotted blood being the most commonly described agent. Given the mixed results in the literature regarding clotted blood and paucity of informa- tion regarding nonclotted blood, we aimed to further evaluate the nonclotted blood patch technique. First, we sought to observe the overall effect on pneumothorax and chest tube placement rates in cases in which a blood patch was successfully used versus cases in which it was not. Second, we wanted to assess feasibility in clinical practice; specifically, we sought to assess the proportion of cases in which the technique was used after a departmental policy change to include nonclotted blood patch as standard practice. Third, we wanted to evaluate the effect of the policy change on pneumothorax and chest tube placement rates in the routine clinical setting, given incomplete use of blood patch after policy introduction, as the ultimate decision to use the technique in each case was left to the individual practitioners. We hypothesized that use of nonclotted blood patch would result in a significant decrease in overall pneumo- thorax and chest tube placement rates compared with the nonclotted blood patch group. We postulated that in practice approximately 80% of patients would receive the patch once it was the “standard” for the department. Finally, we believed that despite incomplete utilization of the technique, the net effect of the blood patch policy would be a statistically significant reduction in pneumothorax and chest tube placement rates. P neumothorax remains the most common complication of percutaneous lung biopsies. Reducing this risk is a goal of those who perform these procedures, particularly reduction in large pneumothoraces requiring intervention (eg, pleural drainage) and hospitalization. Various inter- ventions have been considered to reduce the risk for pneumothorax including avoiding or reducing the number of passes through the pleura, avoidance of areas of From the *Department of Radiology, San Francisco General Hospital; and wDepartment of Radiology and Biomedical Imaging, Uni- versity of California, San Francisco, San Francisco, CA. The authors declare no conflicts of interest. Correspondence to: Joshua D. Clayton, MD, Department of Radiol- ogy, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue Room 1 57, SFGH Box 1325, San Francisco, CA 94110 (e-mail: joshua.clayton@ucsf.edu). Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/RTI.0000000000000215 J Thorac Imaging Volume 31, Number 4, July 2016 MATERIALS AND METHODS Patients This is a HIPPA-compliant, institutional review board–approved, retrospective study. Informed consent was waived. Our institutional lung biopsy database includes all chest biopsies performed, including those for diagnostic and research purposes, at both a tertiary care medical center and a Veterans Affairs medical center, and is main- tained by the biopsy operators. All biopsies from October 2009 through January 2015 were identified, resulting in 999 consecutive potentially eligible procedures. Biopsies were included if it was a procedure in which a blood patch could have been theoretically applied. Therefore, biopsies were excluded if: www.thoracicimaging.com | Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

© 2016, Springer-Verlag Berlin Heidelberg. Background: Games with educational intent offer a possible advantage of being more interactive and increasing learner satisfaction. Objective: We conducted a two-armed experiment to evaluate student satisfaction and content mastery for an introductory pediatric radiology topic, taught by either an interactive digital game or with a traditional didactic lecture. Materials and methods: Medical students participating in a fourth-year radiology elective were invited to participate. Student cohorts were alternatively given a faculty-supervised 1h session playing a simple interactive digital Tic-tac-toe quiz module on pediatric gastrointestinal radiology or a 1h didactic introductory lecture on the same topic. Survey questions assessed the learners’ perceived ability to recall the material as well as their satisfaction with the educational experience. Results of an end-of-rotation exam were reviewed to evaluate a quantitative measure of learning between groups. Survey responses were analyzed with a chi-squared test. Exam results for both groups were analyzed with a paired Student’s t-test. Results: Students in the lecture group had higher test scores compared to students in the game group (4.0/5 versus 3.6/5, P = 0.045). Students in the lecture group reported greater understanding and recall of the material than students in the game group (P < 0.001 and P = 0.004, respectively). Students in the lecture group perceived the lecture to be more enjoyable and a better use of their time compared to those in the game group (P = 0.04 and P < 0.001, respectively). There was no statistically significant difference between the lecture and game group in ability to maintain interest (P = 0.187). In comparison to pre-survey results, there was a statistically significant decrease in interest for further digital interactive materials reported by students in the game group (P = 0.146). Conclusion: Our experience supported the use of a traditional lecture over a digital game module. While these results might be affected by the specific lecture and digital content in any given comparison, a digital module is not always the superior option.

Purpose: The peri-infarct zone represents the morphologic substrate for reentry ventricular tachycardia after myocardial infarction, and its extent is a strong predictor of major cardiac events. Although delayed gadolinium enhancement magnetic resonance imaging (DGE-MRI) was shown to allow for detailed characterization of myocardial infarction by quantifying infarct core zone and peri-infarct zone volume, potentials of DGE-MRI for measuring changes in peri-infarct zone volume are unknown. Therefore, we aimed to assess changes in volume of the peri-infarct zone among patients with ischemic cardiomyopathy treated with chronic vasodilator therapy. Materials and Methods: Core and peri-infarct zone volumes as assessed with DGE-MRI were measured in 5 patients at baseline and after 6 months treatment with sustained-release dipyridamole. Results: Core zone volume remained stable during follow-up [median (range), 19 mL (9 to 42) vs. 16 mL (11 to 46); P=0.785]. The ratio between the peri-infarct zone and the core zone volume decreased significantly at 6 months compared with baseline [median (range), 0.22 (0.19 to 0.42) vs. 0.18 (0.09 to 0.32); P=0.043], and a trend toward reduction in peri-infarct zone volume was found [median (range), 5 mL (2 to 8) vs. 3 mL (2 to 6); P=0.059]. The peri-infarct zone volume decreased in all but 1 patient over the follow-up. Conclusion: This initial experience suggests that reverse remodeling of the peri-infarct zone with reduction in peri-infarct zone volume may take place in patients with ischemic cardiomyopathy. Quantification of this process may be feasible with DGE-MRI, but further studies are needed to confirm this hypothesis and to further clarify the role of DGE-MRI for the assessment of changes in peri-infarct zone volume in patients with ischemic cardiomyopathy. Copyright © 2012 by Lippincott Williams & Wilkins.

The study compared the sensitivity, specificity, confidence and interpretation time of readers of differing experience in diagnosing acute appendicitis with contrast-enhanced CT using neutral vs positive oral contrast agents.Contrast-enhanced CT for right lower quadrant or right flank pain was performed in 200 patients with neutral and 200 with positive oral contrast including 199 with proven acute appendicitis and 201 with other diagnoses. Test set disease prevalence was 50%. Two experienced gastrointestinal radiologists, one fellow and two first-year residents blindly assessed all studies for appendicitis (2000 readings) and assigned confidence scores (1=poor to 4=excellent). Receiver operating characteristic (ROC) curves were generated. Total interpretation time was recorded. Each reader's interpretation with the two agents was compared using standard statistical methods.Average reader sensitivity was found to be 96% (range 91-99%) with positive and 95% (89-98%) with neutral oral contrast; specificity was 96% (92-98%) and 94% (90-97%). For each reader, no statistically significant difference was found between the two agents (sensitivities p-values0.6; specificities p-values0.08), in the area under the ROC curve (range 0.95-0.99) or in average interpretation times. In cases without appendicitis, positive oral contrast demonstrated improved appendix identification (average 90% vs 78%) and higher confidence scores for three readers. Average interpretation times showed no statistically significant differences between the agents.Neutral vs positive oral contrast does not affect the accuracy of contrast-enhanced CT for diagnosing acute appendicitis. Although positive oral contrast might help to identify normal appendices, we continue to use neutral oral contrast given its other potential benefits.

OBJECTIVE. The objective of this article is to describe the CT and MRI findings of early intrauterine pregnancy.CONCLUSION. Early pregnancy should be considered when CT or MRI shows a fluid-filled cystlike structure in the uterus of a woman of reproductive age especially if there is a coexistent ovarian corpus luteum cyst.

Two patients with renal cell carcinoma and one patient with metastasis to the kidney from colorectal cancer are reported because all three cases manifested at computed tomography (CT) as a renal mass invading the pelvicaliceal system and radiologically simulating transitional cell carcinoma. Recognition that the CT finding of a renal mass with invasion of the pelvicaliceal system is not always indicative of a transitional cell carcinoma broadens the differential diagnosis in this setting and might potentially alter the diagnostic and therapeutic approach.

© 2016 American College of Radiology. Purpose The didactic lecture remains one of the most popular teaching formats in medical education; yet, factors that most influence lecturing success in radiology education are unknown. The purpose of this study is to identify patterns of narrative student feedback that are associated with relatively higher and lower evaluation scores. Methods All student evaluations from our core radiology elective during 1 year were compiled. All evaluation comments were tagged, to identify discrete descriptive concepts. Correlation coefficients were calculated, for each tag with mean evaluation scores. Tags that were the most strongly associated with the highest- versus lowest-rated (> or < 1 SD) lectures were identified. Results A total of 3,262 comments, on 273 lectures, rated by 77 senior medical students, were analyzed. The mean lecture score was 8.96 ± 0.62. Three tags were significantly positively correlated with lecture score: "interactive"; "fun/engaging"; and "practical/important content" (r = 0.39, r = 0.34, and r = 0.32, respectively; all P

O RIGINAL A RTICLE Nondiagnostic Computed Tomography–guided Percutaneous Lung Biopsies Are More Likely When Infection Is Suspected Brian M. Haas, MD,* Brett M. Elicker, MD,* Janet Nguyen, MD,* Karen G. Ordovas, MD,* Kirk D. Jones, MD, w Travis S. Henry, MD,* and David M. Naeger, MD* P carry certain risks: most commonly, pneumothorax, and rarely death. 2–4 An additional “risk” is that the biopsy procedure may not yield diagnostic material, either due to a technical failure, insufficient material being obtained, sam- pling error, or inability of the pathologist to confidently identify the true abnormality. 2,5–7 Such an outcome is var- iably called “negative,” “nondiagnostic,” or “nonspecific” in the literature. The rate of nondiagnostic CTLB reported in the lit- erature ranges from 15% to 22%. 2,8 Variability in biopsy success has been attributed to technique, including number of passes, 8 the use of core versus fine-needle aspiration sampling, 9–11 needle trajectory, 12 and having a pathologist present to evaluate the sample. 13 Other groups have pub- lished that nodule characteristics affect the nondiagnostic rate of CTLB, with small size and presence of necrosis leading to lower rates of success. 2,5,8,14 To our knowledge, no studies have investigated the association between the pretest likelihood for cancer versus infection and the non- diagnostic rate. Overall, understanding the nondiagnostic rate on the basis of a set of predictive factors is important to accurately consent patients and to inform referring clinicians who must decide between various diagnostic options to obtain a diagnosis. In this study, we had 2 primary aims. First, we sought to assess the rates of nondiagnostic results on the basis of the pretest suspicion for cancer, infection, or for lesions considered clinically uncertain. Second, we aimed to determine the ultimate clinical diagnosis in patients with nondiagnostic CTLBs, overall and stratified by the pre- biopsy likelihood of the lesion being cancer versus infection. We hypothesized that our overall nondiagnostic rate would be comparable to other institutions. We hypothe- sized that a high pretest likelihood of infection would be correlated with a higher nondiagnostic biopsy rate. We also hypothesized that nondiagnostic biopsies would most commonly represent infections, particularly in cases in which infection was initially suspected. From the Departments of *Radiology and Biomedical Imaging; and wPathology and Laboratory Medicine, University of California, San Francisco, San Francisco, CA. The authors declare no conflicts of interest. Correspondence to: David M. Naeger, MD, Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, Box 0628, San Francisco, CA 94143- 0628 (e-mail: david.naeger@ucsf.edu). Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/RTI.0000000000000207 The institutional review board approved this study and waived requirement of informed consent for this HIPAA-compliant study protocol. All patients presenting for CTLB over a 5-year period between October 1, 2009 and September 30, 2014 at 2 clinical sites were identified for review. The 2 clinical sites included an academic tertiary care hospital and an affiliated Veterans Affairs medical center. All biopsy requests were Purpose: The purpose of this study was to assess the incidence of nondiagnostic computed tomography–guided lung biopsy results, stratified by biopsy indication, and determine the final diagnosis in such cases. Materials and Methods: Following institutional review board approval, pathology results from CT-guided lung biopsies over a 5- year period at 2 institutions were categorized as diagnostic or nondiagnostic. Each biopsy’s indication was categorized as being for a lesion considered likely to be cancer, infection, or uncertain. For all nondiagnostic biopsies, the medical chart was reviewed to determine the final clinical diagnosis. Results: A total of 660 biopsies were evaluated, 139 (21%) of which were nondiagnostic. Of these 139 patients, the final clinical diag- nosis was infection in 37%, cancer in 30%, and a benign non- infectious diagnosis in 10%; 23% remained undiagnosed at last available follow-up. Among the patients in whom there was a high pretest suspicion for cancer, 13% were nondiagnostic, 45% of which were cancer and 27% were infection. Among biopsies of lesions with pretest probability for both cancer and infection, 51% were nondiagnostic; on clinical follow-up these were determined to be infection in 34% and cancer in 14%. When there was high pretest suspicion for infection, 73% were nondiagnostic, of which 13% were cancer on clinical follow-up, and 88% were infection. The rate of nondiagnostic biopsies was statistically significantly different (P < 0.001) among the 3 groups. Conclusions: Nondiagnostic biopsies are common and occur most frequently when there is a moderate or high pretest suspicion for infection. Among all nondiagnostic biopsies, regardless of indica- tion, cancer and infection were diagnosed on follow-up in similar proportions. Key Words: percutaneous lung biopsies, chest biopsies, non- diagnostic, pneumonia, lung cancer (J Thorac Imaging 2016;31:151–155) ercutaneous computed tomography (CT)–guided lung biopsy (CTLB) is an important way to establish a diagnosis of cancer and, in some cases, infection. 1 It is well known that these types of biopsies, although generally safe, MATERIALS AND METHODS J Thorac Imaging Volume 31, Number 3, May 2016 www.thoracicimaging.com | Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

© 2016 The Association of University Radiologists Rationale and Objectives Pulmonary nodules can be missed on the non-breath hold computed tomography (CT) portion of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), and for this reason prior studies have advocated for routinely performing dedicated breath hold CT of the chest in addition to PET/CT for routine staging of malignancy. We evaluated the rate of pulmonary nodule detection on standard CT images from whole body PET/CT studies (WB-PET/CT), high-resolution lung reconstruction CT images from PET/CT studies (HR-PET/CT), and diagnostic breath hold chest CT (BH-CT). Materials and Methods A cohort of 25 patients was identified who had a history of lung cancer as well as a PET/CT staging or restaging scan and BH-CT within 30 days of each other. All PET/CTs included a set of CT images using a soft tissue algorithm filter and 3.75- to 5-mm slice thickness, as well as high-resolution reformats with a sharp reconstruction filter and 2-mm slice thickness. The CT images from WB-PET/CT, HR-PET/CT, and BH-CT were reviewed by three radiologists. Significance was analyzed by two-way repeated measures analysis of variance. Results There were 2.84 nodules found per patient with WB-PET/CT, 3.85 nodules with HR-PET/CT, and 3.91 nodules with BH-CT. When only nodules less than or equal to 8 mm in size were considered, WB-PET/CT also demonstrated significantly fewer nodules (1.98) compared to the HR-PET/CT (2.94) or a BH-CT (2.86) (P

CASE STUDIES IN TRAINING AND EDUCATION Effectively Acquiring and Using Feedback David M. Naeger, MD, Aaron Jen, BA, Bren Ahearn, MA, Emily M. Webb, MD DESCRIPTION OF THE PROBLEM Feedback is a vital component of medical education [1,2]. Feedback can hone an educator’s teaching skills, guide the evolution of a cur- riculum, and improve the experience of students [3,4]. However, feedback systems are easily hampered by pit- falls and often implemented without sufficient scrutiny or review [5]. When feedback is not collected properly, it can be difficult to use. For example, collecting too little feedback can provide insufficient information, and too much feedback (or feedback that has accumulated) can be overwhelming. Delays in receiving or processing feedback limit the likelihood of effecting timely change. When feedback is of poor quality, its utility is decreased [6]. The biggest cause of poor feedback is “feedback fatigue” [7], soliciting feedback so frequently that partic- ipation drops and the results are terse and prone to response bias. Additionally, overly vague or spe- cific feedback has been shown to be less effective [6], as has exclu- sively positive or exclusively nega- tive feedback [8]. Off-the-cuff verbal feedback seems to lack crit- ical analysis, compared with writ- ten feedback [9]. Finally, actually doing some- thing with the feedback is required for it to be effective. Commonly, the energy, time, or motivation required to make improvements is lacking, despite the availability of sufficient feedback. Some studies have suggested that physi- cians, as a group, often tend to overestimate their performance [10], thereby limiting their will- ingness to change. In some cases, feedback must be combined with mentorship to effect meaningful change [5,10,11]. Herein, we discuss a multiyear process of critically reviewing and improving our feedback system in the largest course offered by our department—the core medical stu- dent radiology elective, in which approximately 100 students enroll per year. In particular, we focus on how our feedback systems could improve the instruction provided, while promoting educators and the educational program. WHAT WAS DONE Definition of Feedback Goals Our first step was to create a list of goals for our feedback system. Through a collaborative process, all members of the radiology elective’s leadership determined the charac- teristics of an effective feedback sys- tem, which were as follows: 1. All requested feedback should be useful (ie, actionable): n No redundant questions; n No questions about things that cannot be changed; Questions specifically assessing a targeted area of concern should be removed after sufficient in- formation has been acquired. Feedback should be required of all students, to ensure a repre- sentative set of comments and codify the expectation that everyone is responsible for help- ing improve the educational experience. Feedback should be acquired in a timely manner, ideally the same day as the activity. Feedback should be reviewed in a timely manner, ideally within a few days. Feedback should result in changes (except when the feed- back indicates the current state is as good as can reasonably be achieved). Positive feedback should be used to support and promote educators and the educational program. n To achieve the preceding goals, the leadership decided that both daily feedback and “end-of-course” feedback were needed. Acquiring Daily Feedback Students were asked to provide constructive daily feedback on all activities, via the course’s online learning portal. To minimize “feedback fatigue,” the daily online form was parsimonious, including a required attendance verification question and only 2 n a 2015 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2015.05.011

© 2015 Elsevier Inc. Purpose: The purpose was to test whether patient's primary malignancy type and presence of F-18-fluorodeoxyglucose (FDG)-avid cervical lymph node(s) are predictors of pathologic outcome of incidental focal FDG-avid parotid lesions. Basic procedures: A retrospective cohort study of pathologically proven incidental cases was performed. Main findings: Focal parotid FDG uptake in the setting of head and neck cancer/melanoma [odds ratio (OR)=24.6, P < .01], lymphoma (OR=7.2, P=.02), or FDG-avid cervical lymph node(s) (OR=3.6, P=.07) has a higher odds of representing metastases. No malignant primary parotid tumors were incidentally discovered. Principal conclusions: In patients with head and neck cancer/melanoma, lymphoma, or FDG-avid cervical lymph node(s), there were higher odds that focal parotid FDG uptake was a metastasis.

Author(s): Kathiria, Nazima N; Devcic, Zlatko; Chen, James S; Naeger, David M; Hope, Michael D; Higgins, Charles B; Ordovas, Karen G | Abstract: PurposeBecause left ventricular (LV) enlargement (LVE) is indicative of an array of cardiac pathologies, including cardiomyopathic, ischemic, and valvular heart diseases, it is important to recognize it early in the course of these diseases. The recognition of LVE on nongated contrast-enhanced computed tomography (CT) scans should be facilitated by the availability of a dimensional index. To our knowledge, no CT index of LVE has been proposed. Therefore, the study aimed to define whether the maximum LV diameter (LVd) measured on nongated multidetector computed tomography can identify LVE when referencing echocardiography as the diagnostic standard.Materials and methodsThe patient population consisted of 438 consecutive patients who had a contrast-enhanced, nongated 16- or 64-detector CT of the chest for evaluation of pulmonary embolism or aortic dissection between January 2006 and March 2008. One hundred fifty-five patients in this group also had an echocardiogram within 2 months of the CT study. The maximum LV cavity size, septal to lateral wall dimension, was measured perpendicularly to the long axis of the left ventricle on the axial CT scans by 2 observers blinded to the echocardiography data.An receiver operating characteristic analysis was performed to identify a highly specific cutoff for the diagnosis of LVE on CT, using echocardiogram as the standard of reference. Interobserver agreement was assessed using Bland-Altman analysis.ResultsA total of 84 females and 71 males were evaluated (female to male ratio of 1.09). The mean age for the 155 patients was 58 years. Six percent of these patients had a diagnosis of LVE on 2-dimensional echocardiography. The mean (SEM) LV internal diameter at nongated multidetector computed tomography between the group with normal LV and the group with LVE by echocardiography was 4.4 (0.7) cm for the normal LV and 5.9 (1.2) cm for the dilated LVs (P l 0.0001). With the use of threshold value of LVd of 5.6 cm, a sensitivity of 78%, specificity of 100%, positive likelihood ratio of 113.5, and negative likelihood ratio of 0.22 were calculated. The LVd measurements had an excellent agreement between observers on the Bland-Altman analysis.ConclusionsLeft ventricular enlargement can be reliably identified on nongated contrast-enhanced multidetector CT when the maximum luminal diameter of the LV is greater than 5.6 cm. Nongated contrast-enhanced CT scan can be used to recognize LVE.

© 2015 American College of Radiology. Purpose: Imaging results are generally communicated to patients by referring providers. Directly communicating results has been suggested as a way for radiologists to add value, though few studies have investigated patients' preferences in this regard. The aim of this study was to determine patients' preferences for receiving their imaging results. Methods: In this institutional review board-approved study, adult outpatients undergoing CT or MRI at an academic medical center and an affiliated county hospital over a 4-week period (n= 2,483) were surveyed. The survey assessed patients' preferred delivery method for radiology results and their understanding of radiologists' education and role. Results: A total of 617 surveys (25% response rate) were completed, 475 (77%) and 142 (23%) by academic medical center and county hospital patients, respectively. Among all respondents, the majority of patients (387 of 617 [63%]) preferred models of results delivery centered on the referring physician as opposed to the radiologist. Regardless of who verbally relayed the results, 64% of all respondents (398 of 617) wanted the option to receive a copy of the report, and 522 of 614 (85%) wanted to see their images. Among patients wanting copies of their reports, academic medical center patients expressed equal interest in mail, e-mail, and online portal options (33%, 31%, and 36%, respectively), and county hospital patients preferred mail (55%, 28%, and 17%, respectively) (P < .001). Conclusions: Patients prefer receiving their imaging results through their referring providers. Many patients would also like to view their images and receive copies of their reports, potential avenues through which radiologists could add value.

CASE STUDIES IN TRAINING AND EDUCATION A Designated “Teaching Resident”: A Novel Leadership Position to Promote Educational Skills and an Academic Career Emily M. Webb, MD, Bren Ahearn, MA, David M. Naeger, MD DESCRIPTION OF THE PROBLEM Teaching is considered an essential competency during residency training. The ACGME requires that residents participate in the education of medical students as part of achieving compe- tency in “practice based learning and improvement” and “interpersonal communication” [1]. Furthermore, the Liaison Committee on Medical Education states that residents who supervise medical students “must be prepared for their roles in teaching and assessment” [2]. Beyond these man- dates, however, many resident trainees have an intrinsic interest in teaching, and encouraging and developing their skills may provide the impetus for a successful academic career. Students often describe residents as being among their most influential teachers in medical school [3]. Previous authors have shown that residents can be very effective educators, even as effective as faculty members in some cases [4]. Some radiology residency pro- grams have begun to develop training pathways for clinician educators that focus on obtaining teaching skills during residency [5]. Although these pathways have been described in only a limited fashion in the radiology litera- ture, across disciplines, they have been given a trial in various programs [5-9]. Formats for these programs range from four-week courses [8], to workshops, lectures, and seminars [10], to longi- tudinal experiences described as clini- cian educator pathways for residents that include mentorship, opportunity to develop teaching materials, and often an educational scholarship proj- ect [5,6]. Few programs seem to offer hands-on experience in curriculum design [6], and they rarely, if ever, include educational administration. To our knowledge, none of these pro- grams has any specific emphasis on medical student (as opposed to resi- dent) education in radiology. Our department has a well-developed, integrated medical school curriculum in radiology, and we encourage residents to participate in many of these teaching efforts. During the four-year curricu- lum, approximately 500 formal teaching hours are staffed by radiologists each year; approximately 75% of these hours are taught by faculty members, and the remainder by supervised resi- dents. We saw an opportunity to create a mentored, longitudinal experience, focused on medical student education in radiology, that would concentrate on the additional skills required by faculty clinician educators, including curricu- lum design and educational administra- tion. We hypothesized that designation of a “teaching resident” would en- courage participants’ interest in teach- ing, and their pursuit of an academic career, while increasing the efficiency of our medical student teaching programs. a 2016 American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2015.06.013 WHAT WAS DONE Program Creation In 2008, we designed a new leadership role in the residency for a rising third- year radiology resident, which we called the “Resident Liaison for Med- ical Student Education.” Interested residents apply (n ¼ 14 residents per class), and the best candidate is chosen through a competitive review and vote by the Departmental Medical Student Education Committee. The new “liaison,” or teaching resident, is formally announced each year in similar fashion to the chief residents. The liaison works directly with the two faculty members, adminis- trative leaders for medical student education in the department of radiology, as well as the main med- ical student education coordinator. Their primary tasks/roles include: n n n n n Maintaining a sign-up link on the residents’ website for medical school teaching, with an updated list of teaching opportunities; Recruiting residents for teaching roles in the medical school; Fostering enthusiasm for teaching among the residents; Helping to determine which residents are most qualified to take on more-advanced teaching assignments; Teaching (often the liaison teaches more than a typical resident).

© 2015 Elsevier Inc. Aim: Assess the extent of low- versus high-intensity late gadolinium enhancement (LGE) in hypertrophic cardiomyopathy (HCM). Methods: Low- versus high-intensity LGE indexed volumes in 19 HCM patients were compared to 23 myocardial infarction (MI) patients. Results: Total, low-, and high-intensity LGE volumes in HCM vs. MI were 7.6 ml/m2, 4.7, and 2.4 vs. 11.2, 2.5, and 7.1, respectively. Total LGE volume did not differ (P=13), though low- and high-intensity did (P=05, .004). 67% versus 26% of all LGE was low-intensity in HCM versus MI (P

Background Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization. Purpose To compare the rate of successful RAV sampling in the presence of the IEV. Material and Methods Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling. Results RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling. Conclusion The IEV may serve as a reliable landmark for the RAV during RAV sampling.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Purpose: Left atrial (LA) enlargement is associated with increased risk for adverse cardiovascular events. We assessed the accuracy of LA transverse and antero-posterior (AP) diameters obtained from chest computed tomography (CT) angiography in patients with atrial fibrillation. Materials and Methods: Nongated contrast-enhanced 64-slice multidetector CT angiography (slice thickness of 0.625 to 1.25 mm) was used to measure the volume and transverse and AP diameters of the LA in 222 subjects. The internal contours of the LA and LA appendage were outlined in 1 of every 5 axial images, and the LA area was multiplied by 5 times the slice thickness. Maximum transverse and AP diameters of the LA were measured, excluding the appendage. Receiver operating characteristic curves were fitted to assess the accuracy of the diameters. A Wald test was used to compare the area under the curves. Results: The mean age of patients was 60.0±10.6 years, and 71% were male. Median LA volume was 55.9± 24.4 mL/m 2. LA enlargement was present in 83% of the patients. Transverse and AP LA diameters were accurate estimators of the LA enlargement. The transverse diameter demonstrated higher accuracy than the AP diameter, with area under the curves of 0.89 (0.84 to 0.94) and 0.81 (0.73 to 0.89), respectively (P

Editor: Despite efforts to minimize the incidence of retained surgical instruments, this complication continues to occur in approximately 1 in 8,000–18,000 of all operations (1). Preoperative localization of breast lesions with a hook wire has become a standard radiologic practice (2). This technique is advantageous because the needle is accurately positioned under imaging guidance, and when deployed, the hook maintains the wire in position until the patient can undergo surgical resection of the suspicious lesion. We describe a case of a retained suture needle in the perineum that was successfully localized using a hook wire (Modified Kopans; Cook, Inc, Bloomington, Indiana) and subsequently retrieved. Institutional review board approval was not required for this single retrospective case report. A 30-year-old woman presented to our institution with pain and purulent discharge from her perineum 6 days following a forceps-assisted vaginal delivery with second-degree perineal laceration. On examination, necrotic tissue was present at the edges of the prior laceration repair site, and purulent material was draining from the wound. She underwent incision, debridement, and packing of the wound, in anticipation of a secondary wound closure. During the secondary wound closure procedure, the tissues were approximated using 3-0 polyglactin 910 (VICRYL RAPIDE; Ethicon, Inc, Somerville, New Jersey) sutures. During performance of the crown stitch portion of wound closure, the tip of the suture needle was visualized in the perineal soft tissues, but it could not to be grasped with pickups or a needle driver. Smooth pickups were used to grasp the suture near the base of the needle. When this area of the suture was grasped, the suture detached from the needle, and the needle remained buried in the perineal soft tissues and was not visible or palpable. Limited intraoperative ultrasound of the wound and the perineal soft tissues did not localize the needle. Extensive wound exploration and dissection were not performed because of the patient’s recent history of perineal abscess. Hook wire localization was performed using a helical computed tomography (CT) scanner (HiSpeed Advantage; General Electric Medical Systems, Milwaukee, Wisconsin). An initial CT scan through the right perineum was obtained so that the entry skin site, depth, and angulation of the hook wire needle could be planned with respect to the retained suture needle (Fig 1). The length of the hook wire was determined by the depth required to reach the retained suture needle from the skin surface plus an additional 1.5 cm to position the stiff portion of the hook wire adjacent to the retained suture needle. Using serial CT scans to confirm location, the hook wire needle was positioned past the retained suture needle, and the hook wire was deployed; additional CT images confirmed final placement (Fig 2). The portion of the hook wire external to the patient was secured to the patient with gauze and tape. In the operating room, a sharp dissection from the edge of the vaginal wall in the direction of the hook wire was performed, and the retained suture needle was located and retrieved along with the hook wire. The perineum

Ultrasound is used increasingly in medical practice as a tool for focused bedside diagnosis and technical assistance during procedures. Widespread availability of small portable units has put this technology into the hands of many physicians and medical students who lack dedicated training, leaving the education and introduction of this key modality increasingly to physicians from other specialties. We developed a radiology-led program to teach ultrasound skills to preclinical medical students.To develop this new ultrasound program we 1) established a program leader, 2) developed teaching materials, 3) created a hands-on interactive program, and 4) recruited the necessary instructors. The program was piloted with the first-year medical student class of 154 students. The introductory session was assessed by pre- and post-activity Likert scale-based surveys.Of 154 (68.8%) students, 106 completed a voluntary online survey before starting the program and 145 students (94.2%) completed a voluntary survey after the session. Students found the program educationally valuable (4.64 of 5) and reported that it improved their understanding of ultrasound imaging (4.7 of 5). Students' reported confidence in identifying abdominal organs, intra-abdominal fluid, and Morison pouch that was significantly higher on the postactivity survey compared to the presurvey (P.001 for all).We piloted a radiology-led program to teach ultrasound skills to preclinical medical students. Students found the experience enjoyable and educationally valuable.

Purpose: To compare treatment response after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS). Materials and Methods: A retrospective review of patients who underwent conventional TACE for HCC between January 2005 and December 2009 identified 10 patients with patent TIPS. From the same time period, 23 patients without TIPS were selected to control for comparable Model for End-Stage Liver Disease and Child-Pugh-Turcotte scores. The two groups showed similar distribution of Barcelona Clinic Liver Cancer and United Network of Organ Sharing stages. Target HCC lesions were evaluated according to the modified response evaluation criteria in solid tumors (mRECIST) guidelines. Transplantation rate, time to tumor progression, and overall survival (OS) were documented. Results: After TACE, the rate of complete response was significantly greater in non-TIPS patients compared with TIPS patients (74 vs. 30 %, p = 0.03). Objective response rate (complete and partial response) trended greater in the non-TIPS group (83 vs. 50 %, p = 0.09). The liver transplantation rate was 80 and 74 % in the TIPS and non-TIPS groups, respectively (p = 1.0). Time to tumor progression was similar (p = 0.47) between the two groups. OS favored the non-TIPS group (p = 0.01) when censored for liver transplantation. Conclusion: TACE is less effective in achieving complete or partial response using mRECIST criteria in TIPS patients compared with those without a TIPS. Nevertheless, similar clinical outcomes may be achieved, particularly in TIPS patients who are liver-transplantation candidates. © 2013 Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).

Purpose To compare the rates of hepatotoxicity after transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS) who were stratified into comparable risk groups. Materials and Methods A retrospective review of patients with HCC who were treated with transarterial chemoembolization between January 2005 and December 2009 was performed. Of 158 patients with comparable model for end-stage liver disease (MELD) scores, 10 had a patent TIPS. Hepatobiliary severe adverse events (SAEs) occurring after transarterial chemoembolization were documented. In addition, 1-year survival and liver transplantation rate after transarterial chemoembolization were calculated in each group. Results The incidence of hepatobiliary SAEs after transarterial chemoembolization was nearly two times higher in patients with a TIPS (70%) than in patients without a TIPS (36%; P =.046). The liver transplantation rate 1 year after transarterial chemoembolization was 2.5 times higher in patients with a TIPS (80%) than in patients without a TIPS (32%; P =.004). There was no significant difference in 1-year survival between the two groups after transarterial chemoembolization. Conclusions Patients with HCC and a patent TIPS are more likely to develop significant hepatotoxicity after transarterial chemoembolization than comparable patients without a TIPS in place.

Background: In healthy, HIV seronegative, CMV seropositive adults, a large proportion of T cells are CMV-specific. High-level CMV-specific T cell responses are associated with accelerated immunologic aging ("immunosenesence") in the elderly population. The impact of untreated and treated HIV infection on the frequency of these cells remains undefined. Methodology/Principal Findings:We measured the proportion of CD4+ and CD8+ T cells responding to CMV pp65 and IE proteins was measured using flow cytometry in 685 unique HIV seronegative and seropositive individuals. The proportion of CMV-specific CD8+ T cells was consistently higher in the HIV-seropositive subjects compared to the HIV-seronegative subjects. This HIV effect was observed even in patients who lacked measurable immunodeficiency. Among the HIVseropositive subjects, CMV-specific CD8+ T cell responses were proportionately lower during recent infection, higher during chronic untreated infection and higher still during long-term antiretroviral treated infection. The CD8+ T cell response to just two CMV proteins (pp65 and IE) was approximately 6% during long-term therapy, which was over twice that seen in HIV-seronegative persons. CMV-specific CD4+ T cell responses followed the same trends, but the magnitude of the effect was smaller. Conclusions/Significance: Long-term successfully treated HIV infected patients have remarkably high levels of CMV-specific effector cells. These levels are similar to that observed in the elderly, but occur at much younger ages. Future studies should focus on defining the potential role of the CMV-specific inflammatory response in non-AIDS morbidity and mortality, including immunosenescence. © 2010 Naeger et al.

OBJECTIVE. The purpose of our study was to characterize the clinical and radiographic features of the hyperirritable stomach and to determine if it is associated with extraintestinal causes of nausea and vomiting in the absence of gastric outlet obstruction, gastroparesis, or intestinal obstruction or ileus. CONCLUSION. The hyperirritable stomach was characterized on barium studies in 15 patients by rapid emesis of ingested barium, a collapsed stomach with little or no retained debris or fluid, and normal emptying of residual barium into nondilated duodenum and proximal jejunum. Fourteen (93%) of these 15 patients had extraintestinal causes of nausea and vomiting, and 13 (93%) of 14 with clinical follow-up had marked improvement or resolution of symptoms after treatment. Radiologists therefore should evaluate the stomach and duodenum even after rapid emesis of ingested barium in patients with nausea and vomiting to differentiate a hyperirritable stomach from mechanical or functional gastrointestinal obstruction. © American Roentgen Ray Society.